Updated: 6/19/2017

Genitourinary Trauma

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 Snapshot
  • A 28-year-old male was hit by a car while crossing the road. He sustained abrasions to the face, hands, and bruising over both iliac crests. Blood pressure is 90/55 mmHg and pulse is 110/min. Two large bore IVs are inserted and he was given 1L of Lactated Ringer's, and 2L of crossmatched pRBCs. Scrotal and perineal ecchymosis and swelling, blood at the urethral meatus, and bladder distension up to the umbilicus are present. AP radiographs of the pelvis reveal pelvic fracture (bilateral pubic rami fracture). Retrograde cystourethrogram shows a torn posterior urethra; a suprapubic catheter and a pelvic binder are applied. 
Introduction
  • Genitourinary trauma involves kidney, bladder, and/or urethra
  • 80% is from blunt trauma (MVCs, assaults, falls, crush) vs 20% penetrating (GSW/SW)
  • Blunt trauma to genitourinary organs is associated with pelvic fracture in 97% cases
  • Urethral injury etiology can be divided by posterior and anterior urethra
    • posterior: junction of membranous and prostatic urethra is common site of injury
      • due to shearing force on fixed membranous and mobile prostatic urethra
    • anterior: straddle injury causing crush injury to bulbar urethra against pubic rami
    • iatrogenic: instrumentation, penile fracture
Presentation
  • History
    • mechanism of injury
    • hematuria, blood on underwear
    • dysuria, urinary retention
  • Physical exam
    • abdominal/flank pain, CVA tenderness, upper quadrant mass, perineal lacerations
    • DRE: sphincter tone, position of prostate, presence of blood
    • scrotum: ecchymoses, lacerations, testicular disruption, hematomas 
    • females: bimanual/speculum exam
    • bladder
      • if extraperitoneal rupture: pelvic instability, suprapubic tenderness from mass of urine or extravasated blood
      • if intraperitoneal rupture: acute abdomen
    • urethra
      • flank, scrotal or perianal swelling and bruising
      • gross hematuria
      • high-riding or nonpalpable prostate
      • penile or scrotal swelling or ecchymosis
      • blood in the urethral meatus 
Evaluation
  • Pelvis: radiograph with AP, inlet, and outlet views
  • Urethra: retrograde urethrogram (RUG)
    • if blood at meatus, do NOT insert Foley catheter; perform RUG first
  • Bladder: urinalysis, urethrogram, retrograde cystoscopy +/- cystogram
  • Ureter: retrograde ureterogram
  • Kidney: intravenous pyelogram, CT scan (if hemodynamically stable)
Management
  • Primary and secondary survey with resuscitation (massive transfusion protocol for hemodynamically unstable patients 
  • Pelvis: mechanical stabilization of pelvis
    • pelvic binder  
      • at the level of the greater trochanters
    • external fixator 
      • reduces pelvic volume
    • FAST (Focused assessment with sonography for trauma) exam to assess for intra-abdominal fluid
      • If positive, emergent trip to OR to stop bleeding
      • If negative, can perform diagnostic peritoneal aspirate (DPA) to look for blood
        • If DPA positive, to OR to stop bleeding
        • If DPA negative or not performed (some hospitals do not have this available), can defer OR and continue pelvic stabilization, external fixation, angiography/embolization, or resuscitative endovascular balloon occlusion of the aorta
    • Pelvic angiography and embolization of bleeding vessels may also be performed in hemodynamically stable patients who have evidence of active bleeding on a CT scan of the abdomen/pelvis
      • only stops arterial bleeding
      • does NOT address venous bleeding or bony hemorrhage
  • Urethra: based on location of tear seen on retrograde urethrogram
    • anterior: conservative management
      • if voiding limited: suprapubic cystostomy and antibiotics
    • posterior: suprapubic cystostomy (avoid catheterization) +/- surgical repair
  • Bladder: based on extra vs intraperitoneal rupture
    • extraperitoneal
      • if minor, Foley catheter drainage
      • if major, surgical repair
    • intraperitoneal
      • drain abdomen and surgical repair
  • Ureter: ureterouretostomy
  • Kidney: depends on grade of hematoma / laceration and HD stability
    • minor: conservative management
    • major: surgical repair
 

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Questions (1)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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